Is there a role for homeopathy in cancer care? I think you know the answer to that question…

There, I’ve started off this post the way I start off most posts about homeopathy, with a statement of just how enormous a pile of pseudoscientific (or rather prescientific) quackery that it is. You’d think that in 2015 no one would believe that diluting a substance (with vigorous shaking between each serial dilution step, of course, in order to “potentize” it) makes its effects stronger or that water has some sort of mystical “memory” that remembers the therapeutic substance but forgets all the other impurities, chemicals, and urine with which the water has been in contact over the millennia. Still, homeopaths and naturopaths (all of whom are trained in homeopathy) continue to prescribe little magic sugar pills that have been soaked in the water remaining after a homeopathic remedy has been serially diluted to the point where there’s almost no chance (other than perhaps through contamination of the surfaces of the flasks used to do the dilutions) that there’s even a single molecule of the original remedy left. Such is unreason in 2015, the same as it was over 200 years ago when Samuel Hahnemann dreamt up homeopathy.
What is even more depressing is that there are actual people in medical academia, real doctors, who think there might be something to homeopathy even though its precepts violate multiple well-established laws of physics and chemistry and its other law declaring that “like cures like” has no basis in physiology or medicine. Every so often, I come across articles by such Very Serious People that make their way into actual reputable medical journals. So it was that Mark Crislip (Crissslippppp!) sent me just such an article by Moshe Frenkel, Clinical Associate Professor at the University of Texas Medical Branch, former chair of the Clinical Practice Committee of the Society of Integrative Oncology, former medical director of the Integrative Medicine Program at M.D. Anderson Cancer Center, director of an integrative oncology service in The Institute of Oncology in Meir Medical Center in Israel, and founder and director of Integrative Oncology Consultants. In other words, he’s a former academic who formed his own consulting practice but is still a heavy hitter in the world of academic “integrative oncology.” We’ve met Dr. Frenkel a few times before here, including in posts about his recommendation based on anecdotes of the Feldenkrais method and, perhaps most memorably (at least I like to think so) his study in which he and his colleagues sprinkled the magic water on breast cancer cell lines and misinterpreted probably ethanol toxicity as selective toxicity of homeopathic remedies on breast cancer cell lines. It was a study that Rachael Dunlop also deconstructed in a most excellent fashion. Perhaps the most depressing thing about the study is that it came out of a lab at M.D. Anderson. My deconstruction of that particular study also provoked some of the most hilariously dumb responses I’ve ever had to any post of mine.

Whenever an article’s title is a question, a general rule of thumb is that the answer to the question is no. In that tradition, I was half tempted to let Frenkel ask this question and then answer simply, “No.” Unfortunately, there’s a lot more quackery to deal with; so let’s dig in.

Frenkel starts his article out, as is mandatory for articles by believers about “complementary and alternative medicine” (CAM) or, as it’s now more commonly called “integrative medicine,” with an appeal to popularity, touting how patients with cancer commonly use CAM to “improve their quality of life, to gain a sense of control, and to participate actively in their care.” (One notes that he doesn’t say anything about “to treat their cancers” or “to get better.” Among these, he notes meditation, acupuncture, homeopathy, yoga, and diet. Of course, two of these things are not like the others. For instance, yoga is a system of exercise. Diet and exercise can be science-based methods to assist treating cancer patients. Similarly, meditation might potentially be science-based, although it’s difficult to study. In marked contrast, acupuncture and especially homeopathy are pure quackery. This is a common strategy among CAM apologists, to mix science-based and potentially science-based modalities that have been “rebranded” as being somehow “alternative” and therefore CAM with modalities that are pure quackery, as though they are both equally legitimate. Frenkel thinks this is just damned unfair:

Homeopathy has grown in popularity with the public but is viewed with skepticism by medical academia and is still excluded from current conventional recommendations. Homeopathy is practiced extensively in Europe, Asia, Middle East, and South America to treat functional disorders and minor ailments.

And:

In Europe, homeopathy is used during and after cancer treatments. A survey of close to 1000 cancer patients in 14 European countries revealed that 36%of cancer patients were using some form of complementary medicine. In the surveyed countries, cancer patients often used homeopathy with herbal remedies as the main CIM therapy [6].

In the UK, a questionnaire-based study revealed that homeopathy was one of the mainly used CIM therapies by cancer patients [7].

Approximately 34 % of patients treated in a French cancer department reported using CIM; of these patients, the majority (42 %) used homeopathy [8].

In Germany, cancer patients (both adults and children) tend to use homeopathy in addition to conventional treatments. Homeopathy, as a matter of fact, is the most frequently used CIM treatment among German adults and children with cancer [9, 10].

To which my response is a big yawn. As I like to say, large numbers of people belief in ghosts and hauntings. It doesn’t make ghosts and hauntings real, nor does the popularity of homeopathy in some parts of the world mean that homeopathy is an efficacious treatment for anything.

Even so, having established (or attempted to establish) the popularity of homeopathy, Frenkel next moves on to try to argue that it is also efficacious. A lot of what he writes are the same tired old defenses of homeopathy that I’ve deconstructed ad nauseam right here on this very blog and on my not-so-super secret other blog. It’s still worth discussing some of them again plus one that I somehow missed having discussed in detail, namely a Swiss report on homeopathy released in 2011, which Frenkel exults about:

The Swiss report carefully reviewed the evidence from randomized double-blind and placebo controlled clinical trials testing homeopathic medicines, they also evaluated the Breal world effectiveness^ as well as safety and cost-effectiveness [15]. The report also conducted a comprehensive review of preclinical research such as botanical studies, animal studies, and in vitro studies with human cells. After assessing the evidence from basic science research and high-quality clinical studies, the Swiss concluded that homeopathic remedies seem to induce cellular effects as well as changes in living organisms. The report also mentioned that 20 of the 22 systematic reviews of clinical research, testing homeopathic medicines, detected a trend in favor of homeopathy. The authors concluded that homeopathic treatments should be reimbursed by Switzerland’s national health insurance program, and the Swiss government followed this recommendation [15].

There’s just one problem. It’s a terrible report. Critics almost immediately pointed out (as well they should have) that the Swiss report consisted of a poorly done analysis of the existing evidence. Indeed, David Martin Shaw even characterized it as research misconduct, noting that the writers of the report didn’t even do an online review of the literature because “just searching online would not have been sufficient to supply a representative overview of homeopathic research.” They also included “expert contacts and scanning of bibliographic references.” As Shaw discussed, this is a highly suspect research strategy because any high quality research would be available online via the usual databases such as PubMed.gov and other online sources. More importantly, the “expert contacts” almost certainly suggest biased sources (i.e., homeopaths and naturopaths, the latter of whom also use homeopathy, with perhaps other believers in homeopathy).

Shaw also notes that the authors based “their conclusion that homeopathy is effective on four trials that are all more than a decade old and have been comprehensively exposed as weak, flawed studies (see reference 3 for details of the trials) [3]. The authors also tried to redefine how one determines whether a treatment is safe and efficacious by emphasizing “real world effectiveness,” which, as I’ve pointed out time and time again, is putting the cart before the horse. You can’t look at real world effectiveness until you’ve established efficacy in clinical trials, because design and interpretation of pragmatic studies designed to look at real world effectiveness assume that efficacy has already been established in randomized clinical trials. Both David Shaw and Steve Novella quote a damning passage from the Swiss report:

If homeopathy is highly likely to be effective but this cannot be consistently proven in clinical trials, the question arises of what conditions are needed for homeopathy to show its effectiveness and realise its potential, and what conditions threaten to obscure this?

Shaw expressed surprise that the authors of the Swiss report would be so bold as to come out and say that they are seeking to prove that homeopathy works and looking for conditions under which they can achieve that. As Novella notes, they are assuming that homeopathy works, but are frustrated by the fact that high quality clinical trials uniformly fail to detect efficacy. In any case, Frenkel fails to note that an Australian and British report found exactly the opposite conclusion as the Swiss report. They both concluded that homeopathy doesn’t work detectably greater than placebo. So has a Cochrane review on homeopathy used to treat the adverse effects of cancer treatment, concluding that there is “no convincing evidence for the efficacy of homeopathic medicines for other adverse effects of cancer treatments.” It did note that there were small studies that suggested that topical calendula and Traumeel S mouthwash might have efficacy preventing acute dermatitis during radiation therapy and chemotherapy-induced stomatitis, respectively, but this is weak at best. For one thing, calendula is not truly homeopathic, as it’s not diluted at all, and the tiny Traumeel S study has never been replicated with a larger number of patients.

Frankel also cites poorly done animal studies of homeopathic remedies, including a study of his own that I’ve discussed before, namely the one that demonstrated that the alcohol diluent in homeopathic remedies is toxic to breast cancer cell lines. It was a study so flawed that it took a tag team of Rachael Dunlop and myself to take it down. The rest of the evidence presented consisted of the usual panoply of favored studies of homeopathic remedies, such as best case series of the sort Nicholas Gonzalez used to con the NIH into funding a study of his protocol for pancreatic cancer and survival data in case series with no controls other than historical data.

Frenkel concludes erroneously:

Limited research has suggested that homeopathic remedies appear to cause cellular changes in some cancerous cells. In animal models, specific homeopathic remedies have had an inhibitory effect on tumor development. Studies of homeopathic remedies combined with conventional cancer care show that these remedies improve quality of life, reduce symptom burden, and possibly improve survival in patients with fatal disease. In vitro studies, animal studies, and clinical interventions that combine homeopathy with conventional cancer care suggest that homeopathy might improve the well-being of patients and might affect the progression of cancer and patient survival. These findings warrant comprehensive clinical studies to determine the effects of homeopathy on cancer and patient survival. Although additional studies are needed to confirm these findings, given the low cost and minimal risks and the potential magnitude of homeopathy’s effects, in certain situations, one might consider the use of homeopathic remedies as an additional tool to integrate into cancer care.

Let’s just say that the studies enumerated by Frenkel in his review, as is the case of pretty much every “positive” study touted by homeopaths, do not show what he thinks they show. Certainly, when coupled with the utter implausibility of homeopathy from a scientific standpoint, these studies do not show that homeopathy “works.” As I like to say, equivocal results + an incredibly high degree of scientific implausibility = negative results.

I could have saved Frenkel a lot of time and effort right after the title of his paper by telling him the answer is no. The sad thing is, this is a doctor who was once the chief of “integrative medicine” at one of the two most respected cancer centers in the US and is still well-regarded within academia—I mean quackademia. This should tell you much of what you need to know with respect to what we are up against in fighting the infiltration of pseudoscience into medicine.